Adventure in Food Trading - Upstate New York Specialty Food Distributor

Legal Company Name*

Trade/DBA Name

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different from Shipping Address)

Street Address Address Line 2 City State ZIP Code

Phone*

Email

Have you been in contact with a sales representative?

Yes
No

Business Entity Information

Business Entity*

Corporation
Sole Proprietor
LLC

Name*

First Last

Title of Owner/CEO*

Address

Street Address Address Line 2 City State ZIP Code

Doing Business Since*

Type*

Bank Information

Current Bank

Bank Address

Street Address Address Line 2 City State ZIP Code

Bank Account Number

Have you ever been bankrupt?

Yes
No

Re-Sale ID

This business is*

A/P Billing Contact

Phone

Email

References

Please list three food vendors that are currently extending you credit.

Company Name*

Phone

Address

Street Address Address Line 2 City State ZIP Code

Company Name*

Phone

Address

Street Address Address Line 2 City State ZIP Code

Company Name*

Phone

Address

Street Address Address Line 2 City State ZIP Code

Amount Requested*

Terms Requested*

Payment Agreement

I/we, the undersigned, request Adventure in Food Trading Company to sell and deliver foodstuffs and other merchandise to the responsible party as stated in the application on the reverse side hereof, and further certify that the information provided on the credit application is true and correct. In the event that there is a delinquency in payment, I/we agree that a delinquency charge of 1.5% per month and a ten dollar ($10.00) office fee will be assessed upon the balance due. In the event of a default in payment, I/we will pay to Adventure in Food Trading Company all collection costs and attorney’s fees of 33 1/3% of the unpaid balance. I/we personally and individually guarantee payment in full to Adventure in Food Trading Company, including any and all delinquency charges, collection costs and attorney’s fees incurred as specified above, and waive any presentment, demand, protest or other notice from Adventure in Food Trading Company, regarding this guarantee or payment.

Submission

I verify that all information on this form is accurate to the best of my knowledge. I have the authorization to submit this form on behalf of this entity.

Name*

Title*

Date*

Name

This field is for validation purposes and should be left unchanged.

Customer Application

Business Entity Information

Bank Information

References

Payment Agreement

Submission